Provider Demographics
NPI:1114067261
Name:WADE, STEPHEN (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:
Last Name:WADE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1508 GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502-5178
Mailing Address - Country:US
Mailing Address - Phone:315-798-8737
Mailing Address - Fax:315-732-1702
Practice Address - Street 1:1508 GENESEE ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-5178
Practice Address - Country:US
Practice Address - Phone:315-798-8737
Practice Address - Fax:315-732-1702
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2013-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2426672081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RB3864OtherMEDICARE PTAN
NY03168343OtherMEDICAID
NY03168343OtherMEDICAID